HODGES UNIVERSITY DEPARTMENT OF DENTAL HYGIENE INCIDENT REPORT FORM
DEPARTMENT REPRESENTATIVE MUST FILL OUT THIS FORM This form must be completed following a medical incident. When an incident occurs, the Program Director must be notified and involved student clinician(s) and faculty must complete this form as soon as possible.
Name: ______________________________ Date: ______________ Room or location in which incident occurred: Did anyone observe the incident? If so, list names:
Description of incident: Please describe how the incident happened. What was the individual doing? List any specific acts by individuals or conditions that led to the incident. List any tools, machinery, or instrument(s) involved.
Nature of Incident:
Part of Body Injured:
Abrasion
Fracture
Abdomen
Face
Leg
Bite
Pain/tender
Ankle
Finger
Mouth
Bruise
Puncture
Back
Foot
Nose
Bump
Scrape
Chest
Forearm
Shoulder
Burn
Scratch
Ear
Hand
Teeth
Cut
Sprain
Elbow
Head
Wrist
Dislocation
Splinter
Eye
Knee
Abrasion
Other (specify)
Other (specify)
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Hodges University Student Handbook
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